Eating disorders - Diagnosis
The diagnosis of eating disorders can be problematic in that a number of physical disorders can underpin the condition that will make a psychological approach inappropriate so it is important that psychologists ensure that all potential clients have been physically screened by a qualified physician to exclude these factors The initial diagnosis should be made by a competent medical professional."The medical history is the most powerful tool for diagnosing eating disorders"( American Family Physician).Pritts SD, Susman J.Diagnosis of eating disorders in primary care. Am Fam Physician. 2003 Jan 15;67(2):297-304. 12562151 There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder is made. According to an in depth study conducted by psychiatrist Richard Hall as published in The Archives of General Psychiatry: * Medical illness often presents with psychiatric symptoms. * It is difficult to distinguish physical disorders from functional psychiatric disorders on the basis of psychiatric symptoms alone. * Detailed physical examination and laboratory screening are indicated as a routine procedure in the initial evaluation of psychiatric patients. *Most patients are unaware of the medical illness that is causative of their psychiatric symptoms. *The conditions of patients with medically induced symptoms are often initially misdiagnosed as a functional psychosis.Arch Gen Psychiatry-Vol 35, Nov 1978 Physical Illness as Psychiatric Disease—Hall et al 1319 Medical A consultation with a reputable medical professional who specializes in eating disorders is an indispensable part of both the diagnostic process and treatment. A complete medical and psychosocial history should be provided and a rational and formulaic approach to the diagnosis should be used. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder."Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders,we therefore recommend performing a cranial MRI in all patients with suspected eating disorders"(Trummer M et.al.''2002)","intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective".(O'Brien ''et.al.''2001).Trummer M, Eustacchio S, Unger F, Tillich M, Flaschka G Right hemispheric frontal lesions as a cause for anorexia nervosa report of three cases. Department of Neurosurgery, Karl-Franzens University, Graz, Austria. Acta Neurochir (Wien). 2002 Aug;144(8):797-801; discussion 801. PMID 12181689O'Brien A, Hugo P, Stapleton S, Lask B."Anorexia saved my life": coincidental anorexia nervosa and cerebral meningioma. Int J Eat Disord. 2001 Nov;30(3):346-9. PMID 11746295 Without visible images of neuropathology, psychiatric disorders have been a fertile ground for stigma and bizarre propositions, as evidenced by etiologic theories involving “schizophrenogenic”Neill J. Whatever became of the schizophrenogenic mother? Am J Psychother. 1990 Oct;44(4):499-505. PMID 2285075 and “refrigerator mothers". Neuroimaging will clearly establish psychiatric disorders as being “medical”, thereby bringing these disorders into the mainstream in terms of public attitude and, perhaps more importantly, funding for treating these problems.(Derryck H Smith, MD, Canadian Psychiatric Association) In addition to neuroimaging there are a variety of tests that may be performed to diagnosis and assess the effects of an eating disorder. Psychological After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating ScaleEhle G ''et al.''Psychodiagnostic findings in anorexia nervosa and post-pill amenorrhea. Psychiatr Neurol Med Psychol (Leipz). 1982 Nov;34(11):647-56. PMID 7170321 and the Beck Depression Inventory.Kennedy SH ''et.al.''Depression in anorexia nervosa and bulimia nervosa: discriminating depressive symptoms and episodes. J Psychosom Res. 1994 Oct;38(7):773-82. PMID 7877132 Camargo EE.Brain SPECT in neurology and psychiatry. J Nucl Med. 2001 Apr;42(4):611-23. PMID 11337551 Differential diagnoses Medical '''According to a recent report issued in The Journal of the American Medical Association (JAMA), anywhere from 40,000 to 80,000 deaths in the U.S. are attributable to misdiagnosis in the hospital setting per year.' Also in the U.S., deaths due to medical errors are higher than the numbers attributable to the 8th-leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).Centers for Disease Control and Prevention (National Center for Health Statistics). Births and Deaths: Preliminary Data for 1998. National Vital Statistics Reports. 47(25):6, 1999. Newman-Toker DE, Pronovost PJ, “Diagnostic Errors—The Next Frontier for Patient Safety,” JAMA. 2009;301(10):1060-1062. These figures do not factor in those misdiagnosed outside the hospital setting or for individuals who present with psychiatric symptoms and receive contraindicated i.e. wrong, mental health care predicated upon poor diagnostic procedure. On average, 32,000 Americans commit suicide per year. 77% had seen a physician and 30% had received mental health counseling in the year prior. In England alone independent of the rest of the United Kingdom an average of four psychiatric patients die, many from suicide and another three suffer serious physical harm each day while under the care of the National Health Service.National Comorbidity Survey/ psychminded.co.ukBritain apologizes for 'Third World' hospital *acute pandysautonomia is one form of an autonomic neuropathy, which are a collection of various syndromes and diseases which affect the autonomic neurons of the autonomic nervous system (ANS). Autonomic neuropathies may be the result of an inherited condition or they may be acquired due to various premorbid conditions such as diabetes and alcoholism, bacterial infection such as Lyme disease or a viral illness. Some of the symptoms of ANS which may be associated with an ED include nausea, dysphagia, constipation, pain in the salivary glands early saiety. It also affects peristalsis in the stomach. ANS may cause emotional instability and has been misdiagnosed as various psychiatric disorders including hysterical neurosis and anorexia nervosa.Okada F.Psychiatric aspects of acute pandysautonomia. Eur Arch Psychiatry Clin Neurosci. 1990;240(2):134-5.PMID 2149650 *Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare genetic disorder characterized by gastrointestinal dysmotility, severe cachexia progressive external ophthalmoplegia, post-prandial emesis (vomiting after eating), peripheral neuropathy, and diffuse leukoencephalopathy. Onset is prior to age 20 in 60% of cases. ""Miss A" was a 21-year-old Indian woman diagnosed as having treatment-resistant anorexia nervosa." It was subsequently proven to be MNGIEFeddersen B. Mitochondrial neurogastrointestinal encephalomyopathy mimicking anorexia nervosa. Am J Psychiatry. 2009 Apr;166(4):494-5.PMID 19339372Mitochondrial Neurogastrointestinal Encephalomyopathy Mimicking Anorexia Nervosa ArticleMitochondrial Neurogastrointestinal Encephalopathy Disease *achalasia; There have been cases where achalasia, a disorder of the esophagus which affects peristalsis, has been misdiagnosed as various eating disorders including anorexia nervosa, bulimia nervosa, compulsive eating disorder and obesity related problems. It has been reported in cases where there is sub-clinical manifestation of anorexia nervosa and also in cases where the full diagnostic criteria AN has been met.Riterrrich A,et al.''Achalasia mimicking pre-pubertal anorexia. Int J Eat Disord 2003 Apr.33;(3):356-9 12655633 *superior mesenteric artery syndrome: (SMA) syndrome; "is a gastrointestinal disorder characterized by the compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery resulting in chronic partial, incomplete, acute or intermittent duodenal obstruction". It may occur as a complication of AN or as a differential diagnosis. There have been reported cases of a tentative diagnosis of AN, where upon treatment for SMA syndrome the patient is asymptomatic.Gerasimidis T. Superior mesenteric artery syndrome, Wilkie Syndrome. Dig Surg 2009 26;(3):213-14 PMID 19468230Kornmehl P.Superior mesenteric artery syndrome presenting as anorexia-like illness. J Adolscen Health Care 1988 Jul;9(4):30-3 PMID 3417512 *Lyme Disease is known as the "great imitator", as it may present as a variety of psychiatric or neurologic disorders including anorexia nervosa. "A 12 year old boy with confirmed Lyme arthritis treated with oral antibiotics subsequently became depressed and anorectic. After being admitted to a psychiatric hospital with the diagnosis of anorexia nervosa, he was noted to have positive serologic tests for Borrelia burgdorferi. Treatment with a 14 day course of intravenous antibiotics led to a resolution of his depression and anorexia; this improvement was sustained on 3 year follow-up."Fallon BA, Nields JA. Lyme disease: a neuropsychiatric illness. Am J Psychiatry. 1994 Nov;151(11):1571-83. PMID 7943444Pachner AR. Borrelia burgdorferi in the Nervous System: the New "Great Imitator." In Lyme Disease and Related Disorders. Annals New York Academy of Sciences 539: 56-64, 1988. PMID 3190104 Serologic testing can be helpful but should not be the sole basis for diagnosis. The Centers for Disease Control (CDC) issued a cautionary statement (MMWR 54;125) regarding the use of several commercial tests. Clinical diagnostic criteria has been issued by the CDC (CDC, MMWR 1997; 46: 531-535). *Addison's Disease; is a disorder of the adrenal cortex which results in decreased hormonal production. Addison's disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.Adams R ''et al.''Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting. South Med J. 1998 Feb;91(2):208-11. PMID 9496878 *Simmond's disease (organic hypopituitarism) – "A 20-year-old Japanese man with a hypothalamic tumor which caused hypopituitarism and diabetes insipidus was mistakenly diagnosed as anorexia nervosa because of anorexia, weight loss, denial of being ill, changes in personality, and abnormal behavior resembling the clinical characteristics of anorexia nervosa"(Hotta, M. 1999) *Celiac Disease is an inflammatory disorder triggered by peptides from wheat and similar grains which cause an immune reaction in the small intestine."information on the role of the gastrointestinal system in causing or mimicking eating disorders is scarce."(Leffler DA ''et.al.)Leffler DA, Dennis M, Edwards George JB, Kelly CP.The interaction between eating disorders and celiac disease: an exploration of 10 cases. Eur J Gastroenterol Hepatol. 2007 Mar;19(3):251-5. PMID 17301653 *Gastric adenocarcinoma is one of the most common forms of cancer in the world. Complications due to this condition have been misdiagnosed as an eating disorder.Siew LC, Huang C, Fleming J.Gastric adenocarcinoma mistakenly diagnosed as an eating disorder: Case report. Int J Eat Disord. 2009 Apr 13. ahead of print PMID 19365820 *helicobacter pylori is a bacteria which causes stomach ulcers and gastritis and has been shown to be a precipitating factor in the development of gastric carcinomas. It also has an affect on circulating levels of leptin and ghrelin, two hormones which help regulate appetite. Upon successful treatment of helicobacter pylori associated gastritis in pre-pubertal children they showed "significant increase in BMI, lean and fat mass along with a significant decrease in circulating ghrelin levels and an increase in leptin levels" (Pacifico, L)."SUMMARY: H. pylori has an influence on the release of gastric hormones and therefore plays a role in the regulation of body weight, hunger and satiety,"(Weigt J, Malfertheiner P).Pacifico L, Anania C, Osborn JF, Ferrara E, Schiavo E, Bonamico M, Chiesa C.Long-term effects of Helicobacter pylori eradication on circulating ghrelin and leptin concentrations and body composition in prepubertal children. Eur J Endocrinol. 2008 Mar;158(3):323-325 PMID 18299465Weigt J, Malfertheiner P.Influence of Helicobacter pylori on gastric regulation of food intake. Curr Opin Clin Nutr Metab Care. 2009 Sep;12(5):522-5. PMID 19584718/ *Gall bladder disease which may be caused by inflammation, infection, gallstones, obstruction of the gallbladder or torsion of the gall bladder. Many of the symptoms of gall bladder disease may mimic anorexia nervosa (AN). Laura Daly, a woman from Missouri, suffered from an inherited disorder in which the gall bladder was not properly attached; the resultant complications led to multiple erroneous diagnoses of AN. Upon performance of a CCK test, standard imaging techniques are done with the patient lying prone, in this instance it was done with the patient in an upright position. The gall bladder was shown to be in an abnormal position having flipped over the liver. The gallbladder was removed and the patient has since recovered. The treatment was performed by William P. Smedley, M.D., F.A.C.S.in Pennsylvania. *colonic tuberculosis misdiagnosed as anorexia nervosa in a physician at the hospital where she worked. "This patient, who had severe wasting, was misdiagnosed as having anorexia nervosa despite the presence of other symptoms suggestive of an organic disease, namely, fever and diarrhea"(Madani, A 2002).Tariq A Madani, MD. Colonic tuberculosis clinically misdiagnosed as anorexia nervosa, and radiologically and histopathologically as Crohn's disease Can J Infect Dis. 2002 Mar–Apr; 13(2): 136–140. PMCID: PMC2094857 *Crohn's Disease: "We report three cases of young 18 to 25 year-old girls, initially treated for anorexia nervosa in a psychiatric department. Diagnosis of Crohn's disease was made within 5 to 13 years."(Blanchet C, Luton JP. 2002)"This disease should be diagnostically excluded before accepting anorexia nervosa as final diagnosis". (Wellmann W et al.)Blanchet C, Luton JP.Anorexia nervosa and Crohn disease: diagnostic intricacies and difficulties. 3 cases 3 cases Presse Med. 2002 Feb 23;31(7):312-5. PMID 11899685Holaday M, Smith KE, Robertson S, Dallas J. Adolescence. An atypical eating disorder with Crohn's disease in a fifteen-year-old male: a case study. 1994 Winter;29(116):865-73. PMID 7892797Wellmann W, Pries K, Freyberger H. of Crohn's disease and anorexia nervosa signs and symptoms. Dtsch Med Wochenschr. 1981 Nov 6;106(45):1499-502. PMID 7307984Rickards H, Prendergast M, Booth IW. Psychiatric presentation of Crohn's disease. Diagnostic delay and increased morbidity. Br J Psychiatry. 1994 Feb;164(2):256-61. PMID 8173832 *[[Insulinoma]s, are (pancreatic tumors) that cause an overproduction of insulin causing hypoglycemia. Various neurological deficits have been ascribed to this condition including misdiagnosis as an eating disorder.Grant CS.Insulinoma. Best Pract Res Clin Gastroenterol. 2005 Oct;19(5):783-98. PMID 16253900Shanmugam V, Zimnowodzki S, Curtin J, Gorelick PB.Hypoglycemic hemiplegia: insulinoma masquerading as stroke. J Stroke Cerebrovasc Dis. 1997 Jul-Aug;6(5):368-9. PMID 17895035Morgan JR.A case of Down's syndrome, insulinoma and anorexia. J Ment Defic Res. 1989 Apr;33 ( Pt 2):185-7. PMID 2542562Olsen DB, Abraham JH.Neuropsychiatric disorders in insulinoma Ugeskr Laeger. 1999 Mar 8;161(10):1420-1. PMID 10085751Vig S, Lewis M, Foster KJ, Stacey-Clear A.Lessons to be learned: a case study approach insulinoma presenting as a change in personality. J R Soc Promot Health. 2001 Mar;121(1):56-61. PMID 11329699 *hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder.Mannucci E et al..Eating behavior and thyroid disease in female obese patients. Eat Behav. 2003 Aug;4(2):173-9.PMID 15000980Byerley B, Black DW, Grosser BI. Anorexia nervosa with hyperthyroidism: case report. J Clin Psychiatry. 1983 Aug;44(8):308-9. PMID 6874653Krahn D. Thyrotoxicosis and bulimia nervosa. Psychosomatics. 1990 Spring;31(2):222-4. PMID 2330406Tiller J ''et al.''The prevalence of eating disorders in thyroid disease: a pilot study. J Psychosom Res. 1994 Aug;38(6):609-16. PMID 7990069Fonseca V, Wakeling A, Havard CW.Hyperthyroidism and eating disorders. BMJ. 1990 Aug 11;301(6747):322-3. PMID 2393739Birmingham CL, Gritzner S, Gutierrez E. Hyperthyroidism in anorexia nervosa: case report and review of the literature. Int J Eat Disord. 2006 Nov;39(7):619-20. PMID 16958126D Mattingly and S Bhanji Hypoglycaemia and anorexia nervosa. J R Soc Med. 1995 April; 88(4): 191–195. PMCID: PMC1295161Ozawa Y, Koyano H, Akama T. Complete recovery from intractable bulimia nervosa by the surgical cure of primary hyperparathyroidism. J Eat Disord. 1999 Jul;26(1):107-10. PMID 10349592 *Multiple sclerosis (Encephalomyelitis disseminata) is a progressive autoimmune disorder in which the protective covering (myelin sheath) of nerve cells is damaged as a result of inflammation and resultant attack by the bodies own immune system. In its initial presentation MS has been misdiagnosed as an eating disorder.Dick B. Encephalomyelitis disseminata: a rare, but challenging differential diagnosis of anorectic disorder. World J Biol Psychiatry. 2002 Oct;3(4):225-8.PMID 12516315 *cestodes (tapeworm) infestations can affect various regions of the human body including the gastrointestinal and neuroendocrine systems. While most of those infected are asymptomatic, infestations can cause psychiatric symptoms, epilepsy, megoblastic anemia, weight gain or loss. **Cysticercosis is an infection caused by the larval stage of the pork tapeworm (Taenia solium). The larval stage of T. solium can create cysts in various regions of the body including the brain (neurocysticercosis). Hypothalimic cysticercosis has been associated with obesity. Cysts may form in the bile and pancreatic ducts causing full or partial obstruction some of the symptoms may include weight loss, anorexia, or increased appetite.Lino RS Jr, Reis MA, Teixeira VP. Occurrence of encephalic and cardiac cysticercosis Cysticercus cellulosae in necropsy. Rev Saude Publica. 1999 Oct; 33(5):495-8. PMID 10576752Sheth TN, Pillon L, Keystone J, Kucharczyk W. Persistent MR contrast enhancement of calcified neurocysticercosis lesions. AJNR Am J Neuroradiol. 1998 Jan;19(1):79-82. PMID 9432161 Differential diagnoses/ Comorbid medical disorders There are multiple medical conditions which may misdiagnosed as a primary psychiatric disorder. These may have have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed ED. They also may make it more difficult to diagnose and treat an ED. *Lupus: 19 psychiatric conditions have been associated with systemic lupus erythematosus (SLE), including depression and bipolar disorder.Neuropsychiatric systemic lupus erythematosus presenting as bipolar I disorder with catatonic features. Alao AO, Chlebowski S, Chung C. Psychosomatics. 2009 Sep-Oct;50(5):543-7. PMID 19855042 *Toxoplasma seropositivity even in the absence of symptomatic toxoplasmosis has been linked to changes in human behavior and psychiatric disorders including those comorbid with eating disorders such as depression. In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.Kar N, Misra B.Toxoplasma seropositivity and depression: a case report. Kar N, Misra B. BMC Psychiatry. 2004 Feb 5;4:1. PMID 15018628 *neurosyphilis;It is estimated that their may be up to one million cases of untreated syphyilis in the U.S. alone. "the disease can present with psychiatric symptoms alone, psychiatric symptoms that can mimic any other psychiatric illness". Many of the manifestations may appear atypical. Up to 1.3% of short term psychiatric admissions may be attributable to neurosyphilis, with a much higher rate in the general psychiatric population. Neurosyphilis like Lyme Disease has been given the appellation the "great imitator" for it may present in various ways such as depression and chronic alcoholism. (Ritchie, M Perdigao J,)Ritchie MA, Perdigao JA. Neurosyphilis: Considerations for a Psychiatrist. Louisiana State University School of Medicine Department of Psychiatry Neurosyphilis *dysautonomia a term used to describe a wide variety of autonomic nervous system (ANS) disorders may cause a wide variety of psychiatric symptoms including anxiety, panic attacks and depression. Dysautonomia usually involves failure of sympathetic or parasympathetic components of the ANS system but may also include excessive ANS activity. Dysautonomia can occur in conditions such as diabetes and alcoholism. Differential diagnoses/Comorbid psychological disorders There are separate psychological disorders which may be misdiagnosed as an eating disorder. *Emetophobia is an anxiety disorder characterized by an intense fear of vomiting. A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands. They may become socially withdrawn to avoid situations which in their perception may make them vomit. Many who suffer from emetophobia are diagnosed with anorexia or self-starvation. In severe cases of emetophobia they may drastically reduce their food intake.Lipsitz JD, Fyer AJ, Paterniti A, Klein DF. Emetophobia: preliminary results of an internet survey. Depress Anxiety. 2001;14(2):149-52. PMID 11668669Boschen MJ. Reconceptualizing emetophobia: a cognitive-behavioral formulation and research agenda. Anxiety Disord. 2007;21(3):407-19. Epub 2006 Aug 4. PMID 16890398 *phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting. persons with this disorder may present with complaints of pain while swallowing.Shapiro J, Franko DL, Gagne A. Phagophobia: a form of psychogenic dysphagia. A new entity. Ann Otol Rhinol Laryngol. 1997 Apr;106(4):286-90.PMID 9109717 *Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterized by excessive rumination over an actual or perceived physical flaw. BDD has been diagnosed equally among men and women. While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 39% of eating disorder cases. BDD is a chronic and debilitating condition which may lead to social isolation, major depression and suicidal ideation and attempts. Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing. There is a reported case of the development of BDD in a 21 year old male following an inflammatory brain process. Neuroimaging showed the presence of new atrophy in the frontotemporal region.Gabbay V. New onset of body dysmorphic disorder following frontotemporal lesion. Neurology. 2003 Jul 8;61(1):123-5.PMID 12847173Phillips KA,''et al.''A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994;30(2):179-86.PMID 7831453Feusner JD, Townsend J, Bystritsky A, Bookheimer S.Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry. 2007 Dec;64(12):1417-25.PMID 18056550Feusner JD, Yaryura-Tobias J, Saxena S.Body Image. The pathophysiology of body dysmorphic disorder. 2008 Mar;5(1):3-12. Epub 2008 Mar 7.PMID 18314401Feusner JD, Townsend J, Bystritsky A, Bookheimer S. Arch Gen Psychiatry. 2007 Dec;64(12):1417-25. Visual information processing of faces in body dysmorphic disorder. PMID 18056550 References